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STATE OF CALIFORNI6 WATER RESOURCESCONTRWOARD " <br /> FORM V: UNDERGROUND STORAGE TANK PR RAM TANK PERMIT APPLICATION INFORMATION <br /> TANK <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. ' <br /> MARK ONLY .4EW PERMIT F-13 RENEWAL PERMIT 5 CHANGE OF INFORMATION 91 P ANENTLY CLOSED TANK <br /> ONE ITEM 2INTERIM PERMIT 4AMENDED PER <br /> 6TEMPORARY TANK CLOSURE TANK REMOVED <br /> . <br /> a - FARMTANK-YES❑ NO z <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: o <br /> i© <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY <br /> A. OWNERS TANK ID# U B. MANUFACTURED BY: <br /> C.YEAR INSTALLED 41 1(- D. TANK CAPACITY IN GALLONS: Z S ` W <br /> II. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. 1 MOTOR VEHICLE FUEL n ?PETROLEUM B. C. ❑ 1 UNLEADED 2 LEADED 3 DIESEL <br /> 3 CHEMICAL PRODUCT 4 01L PRODUCT ❑4 GASAHOL 5 FUEL ❑6 AVIATION GAS <br /> 5 HAZARDOUS BO EMPTY 95 UNKNOWN 2 WASTE T METHANOL 99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF 3� C.A.S.#: <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.N (/l•� <br /> 3111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,A D <br /> A TYPE OF ❑1 UBLE WALLED 3 SINGLE WALLED WITH EXTERIOR LINER 95 UNKNOWN <br /> SYSTEM IVSINGLEWALLEO 1 SECONDARY CONTAINMENT 99 OTHER <br /> 1 STEEL/IRON 2 STAINLESS STEEL 3 FIBERGLASS 4 STEEL CLAOWIFIBERGLASS REINFORCED PLASTIC <br /> B.TANK Q 5 CONCRETE 6 POLYVINYLCHLORIDE7 UMINUM B 100Ya METHANOL COMPATIBLE FRP <br /> MATERIAL ❑9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN 99 OTHER <br /> 1 RUBBER LINED 2 ALKYD LINING 3 EPDXY LINING NOLIC LINING <br /> C.INTERIOR 5 GLASS LINING F-1 6 UNLINED LY95 UNKNOWN <br /> LINING <br /> IB LINING MATERIAL COMPATIBLE WITH IOB%METHANOL? YES Ej NO El 99 OTHER <br /> ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT 3 LWRAP E]4 FIBERGLASS REINFORCED PLASTIC <br /> D. CORROSION <br /> PROTECTION 5 CATHODICPRUTECTION E]91 NONE 95 UNKNOWN 99 OTHER <br /> IV. PIPING INFORMATION, CIRCLE A IF ABOVE GROUND, U IF LINDE ROUND,BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A 9 OTHER <br /> NCH A U UNKNOWN A U 99 OTHER <br /> B. CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRE <br /> A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE IPM) A U 4 FIBERGLASS METHANOL <br /> C. MATERIAL A U 5 ALUMINUM A 6 CONCRETE A U 7 STEELCLADW/FRP A U B 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL q U P5 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> p 8 1 VISUAL CHECK P 8 2 INVENTORY RECONCILIATION P 3 VADOSE WELLS S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P S 91 NONE 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 2. ESTIMATED QUANTITY OF 3.WAS TANK GILLED WITH <br /> 1.ESTIMATED DATE LAST USED(M SUB <br /> SUBSTANCE REMAINING IN /' INR RIALP YES D NO <br /> U ` GALLONS <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> DATE <br /> APPLICANT'S NAME(PRINTED 8 SIGNATURE) <br /> LOCAL AGENCY USE ONLY <br /> ,/�� IF ILII II <br /> COUNTY#'--"-T JURISDICTION <br /> � AGES-�-� FACILITYFN9 <br /> a �APPROVED BY NAMECURRENT LOCAL AGENCY FACILL�tl w,r-1 <br /> PERMIT NUMBER 'V MLJI/ PER MIT APPROVAL DATE PERMIT %PIRATI NDAA <br /> CHECK N PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT N <br /> BY: <br /> FORM B(3-7-B6) THIS FORM MUST BE A..COMPANI A FACILIYYlSORT AAP PROCESS NG COPA',UNLESS .TRENT FORM W HAS BEEN FILED / <br />